A + A Assureurs Associés SA

Etude, placement et gérance de portefeuilles d’assurances

Place St-Gervais 1 I CP 1213 I CH-1211 Genève 1

t +41 22 716 19 19 I f +41 22 731 85 21

info@synerisk.ch I www.synerisk.ch

Membre de

Insurance Claim	Motor Vehicle Insurance

Insurance Data

Type of Damage:

Personal liability (Material damage and/or bodily injury to third parties)	Partial accidental damage coverage (Fire, natural damage, snow slide, theft, animals, broken glass, vandalism or fallen objects)
Full accidental damage coverage (Collision)	Parking damage
Personal belongings (Theft of personal belongings inside a locked vehicle)	Accidents (Driver and/or passenger)

Insurance Company
Contract Number
Claim file number (for the insurer)

Policy Holder Information

Last name, first name or company
Street, postal code, city/town
Work Phone	Fax
Email	Mobile

Bank data

Bank & location
Bank account number
IBAN or CCP
BIC

Other

Are you subject to VAT?	Can you reclaim VAT?
Yes No	Yes No

Do you have legal protection insurance?	Yes No
With which company?
Did you report the case?	Yes No

Vehicle used at the time of the accident (according to the indications of the circulation permit)

Brand and model	License Plate Nbr	Registration Nbr	Châssis Nbr
1st release (day month Year)	Number of passengers (driver included) during the accident	Paid transportation?	Mileage
Yes No
Was the vehicle a rental?
Yes No

Driver of the aforementioned vehicle

Last name	Address
First name	City/Town
Birth date	Country
Profession	Phone Number

Valid driver’s license?	Category	Issue date (DD/MM/YYYY)	Did the policy holder authorize the driver to drive?
Yes No	Yes No

In the case of a learner driver: name of the accompanying person	License issue date (DD/MM/YYYY)	Category

Incident

Date	Time	Atmospheric/infrastructural conditions
morning afternoon

Street and location
Outside of town limits Within town limits

Possible witness(es)

Last name, first name, address	Phone number

A votre avis, qui a commis une faute et laquelle ?

*	In the event of theft of the vehicle or personal effects inside the vehicle, a police report is mandatory. Report the crime immediately to the nearest police station!

Police report* ?
Yes No

A quel poste de police	Phone number

Circumstances of the incident

Description of the occurrence	Sketch

Injured persons If there is more than one, please use an additional sheet

Last name	Address
First name	City/Town
Birth date	Phone number.
Profession/Employer
Civil status

In my vehicle	In another vehicle Cyclist	Cyclist	Pedestrian

Related to the policy holder?	Insurance:
Yes No	Suva LAAO LAMal Other: Which insurance?

Inability to work?	Doctor/Hospital (name, address, phone)	Were you wearing a seatbelt?
Yes No	Yes No

Damage to the opposing party's vehicle If there is more than one, please use an additional sheet

Policy Holder (last name, first name and address)	Phone Number

Driver (last name, first name and address)	Phone Number

Make and type, license plate number

Insured for liability?	Yes No	Veuillez indiquer par une le point de choc et marquer les parties endommagées par une x
Which insurance?
Partial accidental damage coverage?	Yes No
Full accidental damage coverage?	Yes No
Which insurance?
Who will make the repairs (company, address, phone) and when?
Repair costs (approximate, in CHF) ?

Other damaged objects (signal, bicycle, animal, hedge, field, luggage, personal belongings, etc.) If there is more than one, please use an additional sheet

Designation of the object, nature of the damage	Damage cost (approximate, in CHF) ?

Injured, owner (last name, first name and address)	Phone number

Was the injured party in the insured vehicle?	Related to the policy holder?	Relationship	Was the object being transported free of charge?
Yes No	Yes No	Yes No

Damage to own vehicle The insurer must give their approval before giving the repair order

Nature of the damage, description of the stolen objects	Please indicate with an the point of impact and mark the damaged parts with an x
Who caused the damage?
In the event of a collision, who is the opposing liability insurer?
Who will make the repairs (company, address, phone)?
Starting when?
Repair costs (approximate, in CHF) ?

Authorization The undersigned authorizes the insurance company to request all information concerning the claim from the insured or third parties and to consult the official and legal documents relating to the claim. The insurance company is also authorized to transmit data relating to the claim to official or judicial institutions and to other insurance companies (co-insurer or reinsurer) in Switzerland and abroad. The undersigned is requested to refrain from accepting any claim of liability before contacting the insurance company. All correspondence will pass through the insurance broker for supervision and support as needed. Important reminders Article 3 of the Federal Law on Insurance Contracts (LCA) provides that the policyholder must do everything possible to limit the damage and notify the insurance company of the loss immediately. Article 46 of the Federal Law on Insurance Contracts (LCA) provides that the claims arising from the insurance contract are time-barred two years from the date of the occurrence of the obligation for contracts taken out before 31.12.2021 and five years from the date of the occurrence of the obligation for contracts taken out from 01.01.2022. You must comply with the time limit. Date and location: Policy holder’s signature and stamp __________________________ _____________________________________